Problem behavior and psychiatric impairment within a developmentally disabled population III: Psychotropic medication

Research m Developmental Disabiliries. Vol. 9. pp. 23-38. Printed in the USA. All rights reserved.

08914222/88 13.00 + .OO Copyright 0 1988 Pergamon Journals Ltd.

1988

Problem Behavior and Psychiatric Impairment Within A Developmentally Disabled Population III: Psychotropic Medication John M! Jacobson New York State Office of Mental Retardation

and Developmental Disabilities

This report is the third in (I series on problem behavior and psychiatric impairment in (I population of 35,000 individuals receiving developmental disabilities services. Young and middle-aged adults werefound to receive psychotropic medication at higher rates than children, adolescents, or elderly persons. Psychotropic receipt rates were found to increase with increasing severity of mental retardation, but most evidently with increasing restrictiveness of residential setting, increasing rated severity of problem behoviors, and presence of a psychiatric impairment. Rates of medication receipt also varied as a function of psychiatric diagnostic category. Discussion remarks emphasize the need to include information relative to clinical and social aspects of program settings and the roles and decision-making performance of physicians and psychologists in research on settings serving persons with developmental disabilities.

It is recognized that interpersonal adjustment and behavioral problems can contribute to placement failure for persons with mental retardation, and these problems indicate possible targets for psychotropic intervention; that is, use of antipsychotic and other medications to alter social functioning or behavior; (deSilva & Higgenbottom, 1983; Eyman & Call, 1977). Studies have suggested, moreover, that placement and organizational variables

Requests for reprints should be addressed to John W. Jacobson, Planning Unit, New York State Office of Mental Retardation and Developmental Disabilities, 44 Holland Avenue, Albany, NY 12229-1000.

23

24

J. W Jacobson

are important, above and beyond client variables, in affecting prescription of psychotropics and detection of adverse effects (Greer, Davis, & Yearwood, 1977, 1978; Intagliata & Rinck, 1985; Mouchka, 1985). It has also been noted that psychotropic medication effects are inadequately monitored and assessed, and that these medications are overprescribed for mentally retarded persons (Agran & Martin, 1985; Breuning & Poling, 1982; Gualtieri & Keppel, 1985; Schroeder, Sprague, Gualtieri, & Thompson, 1986; Szymanski & Cracker, 1983). Correspondingly, efforts have been directed to improved psychotropic prescription and review practices in residential facilities and have produced reductions from 20% to 50% of basal prescription rates (Davidson, Hemingway, & Wysocki, 1984; Schalock, Foley, Toulouse, & Stark, 1985). It is possible that as few as 15% of persons with mental retardation receiving neuroleptics (antipsychotic medications) will show a positive response (Breuning & Poling, 1982) and about 20% of such persons will show adverse reactions (Aman, 1983, 1984; Schroeder, Rojahn, & Mulick, 1978; Sisson & Breuning, 1983). The prevalence of psychotropic medication use has been studied in public residential facilities (PRFs) (Pullman, Pook, & Singh, 1979), in and among types of community care facilities (CCFs) (Martin & Agran, 1985), and in special education settings (Gadow, 1985). A small number of studies have compared prevalence rates between PRFs and CCFs (Hill, Balow, & Bruininks, 1985; Intagliata & Rinck, 1985), between persons living with family or in CCFs (Aman, Field & Bridgman, 1985), or throughout a state service system (MacEacharon, 1983). In PRFs, from 40% to 66% of residents have been reported to receive medication with psychoactive properties. Among CCFs, from 36% to 60% of residents have been reported to receive psychoactive medication depending on the type of CCF. Rates at which psychoactive medications were prescribed to persons living with family have ranged from 7% to 33% and prescription rates have generally been lower for children than for adults. Many studies have considered only certain types of living situations or selected age groups, or a small geographic area, or have failed to discriminate behavioral applications of medication from antispasticity or anticonvulsant uses. Studies that cover larger geographic areas have not uniformly reported findings in regard to intellectual level, age, presence of psychiatric impairment, severity of problem behavior, and the full range of residential contexts. The present study presents data on the prevalence of psychotropic drug use based on these variables throughout one state’s service system, inclusive of persons living with family, in CCFs, and in PRFs. Of particular concern was whether persons with reported psychiatric impairment were consistently receiving psychotropic medication as a treatment strategy.

Psychotropic Medication

25

METHOD

Population The sample for this study consisted of 35,007 mentally retarded persons residing with their families, in community care facilities (foster care, community residences, small intermediate care facilities for the mentally retarded [ICFs/MRJ), or developmental centers (state-operated institutions). This sample represents 96.3% (N=22,536) of persons in these residential programs and an estimated 13% (N= 12,071) of persons living with family in 1985. The latter sample is generally representative of the projected age structure of the population living with family, and represents individuals receiving day program and support services or who are awaiting care. Persons with a current classification of intellectual level within the mild to profound ranges of mental retardation were included in the sample. Of these individuals, 3,341 (9.5%) had been classified as having a psychiatric disability in addition to one or more developmental disabilities (autism, cerebral palsy, epilepsy, mental retardation, or other neurological impairment). In analyses, psychotropic medication receipt of persons with both psychiatric and developmental disabilities (termed PDD) was compared to that of persons with solely developmental disabilities (termed DD). Demographic and diagnostic characteristics of these groups are summarized in Table 1, as are the characteristics of persons according to whether they receive psychotropics. These samples are generally comparable in characteristics to those previously reported by Jacobson (1982a). Instrument

Data on age, intellectual level, residential setting, diagnoses, problem behavior, and medication receipt was extracted from the New York Developmental Disabilities Information System data base (DDIS) (Janicki & Jacobson, 1982). The DDIS is a comprehensive, population-based survey form used to collect data on persons with developmental disabilities in New York State. Readers are referred to Janicki and Jacobson (1982) for a description of the survey form and process, and to Jacobson and Janicki (1985) for a summary of procedures used to enhance data accuracy. Entry of data regarding intellectual level, diagnoses of developmental disability or psychiatric impairment, medication receipt, and a maximum of three problem behaviors is contingent upon the presence of substantiating material in the individual program plan. State Education Law and State regulations permit the entry of diagnoses of psychiatric impairment in program plansby physicians and psychologists. Psychiatric diagnoses rendered prior to 1980 were coded according to DSM-II (American Psychiatric Association, 1968). Psy-

0.6 1.0 63.2 16.7 18.6

57.2 42.8

36.7 26.8 19.8 16.7

34.3

Age (years) o-4 5-20 21-44 45-64 65 +

Sex Male Female

Intellectual Level Mild MRa Moderate MR Severe MR Profound MR

Residential Setting Live with kin

Characteristic

% Psychiatric/ Developmentally Disabled (PDD) (N= 3,341)

34.5

20.9 23.7 23.7 31.7

55.0 45.0

2.6 3.9 54.1 15.9 26.5

% Developmentally Disabled (DD) (N= 3 1,666)

Characteristics

TABLE I. Population

%

13.0

17.1 20.1 26.4 36.4

57.5 42.5

0.2 1.2 64.1 20.6 13.9

Persons Receiving Psychotropics (N= 8,753)

%

41.8

24.2 25.3 22.2 28.2

54.4 45.6

3.1 0.9 51.9 14.4 29.7

Persons Not Receiving Psychotropics (N= 26,254)

(100.0) 7.3 20.3 3.6 12.1 7.5 52.7

II.4 18.4 40.0 30.2 62.3

Psychiatric Impairments Organic brain syndrome Psychosis Neurosis Personality disorder Child behavior disorder Unspecified/other Rated Severity of Behavior None (0) Mild (l-7) Moderate (8- 15) Severe ( 16-29) Receive Psychotropics

51.8 19.1 19.6 9.5 0.0

100.0 21.1

(4.8) 0.5 0.7 0.3 0.7 0.5 2.1

2.5 14.5 22.8 100.0 15.9

32.2 26.0

II.1 16.1 36.1 36.7

(23.8) 1.3 5.4 0.5 2.6 1.2 13.7

4.2 5.6 21.1 100.0 II.3

34.0 53.0

44.5 18.3 22.2 15.0

(0) 0 0 0 0 0 0

2.2 12.1 20.2 100.0 12.9

31.8 33.7

*MR = mental retardation. bDSM-II categories of percentages may not add to 100% due to persons with multiple diagnoses.

7.5 4.9 16.9 100.0 14.5

40.9 24.8

Disabilities Autism Cerebral palsy Epilepsy Mental retardation Neurological impairment

Community living facility Institution

28

J. kK Jacobson

chiatric diagnoses subsequent to 1980 are reported as DSM-III (American Psychiatric Association, 1980) codes; specific codes are not retained in the data base and post-1980 diagnoses are reported as “unspecified.” Relative rates of known DSM-II categorical diagnoses correspond closely between the original and later population samples (r(7) = .95,p< .OOl). This, in turn, suggests that currently unspecified cases consist predominently of persons with psychosis, organic brain syndrome, personality disorder, and child behavior disorder diagnoses. The user’s guide for the DDIS (Office of Mental Retardation and Developmental Disabilities, 1978) specifies that receipt of prescription drugs be recorded, with the exception of those prescribed PRN (“as needed”). Psychotropic drugs are defined as those “prescribed as mood-altering agents, for hyperactivity, depression, etc.” with examples given of “mellaril, thorazine, stelazine, serentil, tofranil, sedatives, and stimulants.” The specific class of psychotropic medication administered is not recorded in the DDIS data base. In order to establish convergent validation and assess data stability, two analyses were conducted. The first compared medication rates for 13 of New York’s institutions in the DDIS with pharmacy drug orders for antipsychotic medications and found that rates were similar (r(12)= .79, p< .OOl). Comparable centralized pharmacy data was not available for CCFs or seven other PRFs. The second analysis found that, over a 6-month period during which 50% of each facility’s DDIS data was updated, medication rates were similar within institutions (r(19) = .98, p < .OOl). These findings document convergent validity and cross-time stability of the medication rate data.

Procedure

Comparisons of psychotropic medication rates were drawn among groups defined by age, intellectual level, psychiatric impairment, severity of reported problem behaviors, and combinations of these variables. Behavior severity ratings were based on a scale (Jacobson, 1982b) assigning weights of from one to ten for each behavior and summing these weights for the three behaviors within subjects (possible range of O-29 points for each case). In analyses, intellectual level groups were defined as mild, moderate, severe, or profound mental retardation (MR), residential settings were defined as living with family, community care facility, and institution; behavior severity groups were defined as summed weights of 0 (none), l-7 (mild), 8-15 (moderate), and 16-29 (severe) points; and age groups were defined as birth to 4 years, 5 to 21,21 to 44,45 to 64, and 65 years or older. Psychiatric impairment was treated as a dichotomous variable (present/not present) for each person.

Psychotropic Medication

29

Unequal cell sizes, and especially small cell sizes for younger age groups, prohibited crossing of more than three variables in analyses. Consequently, analyses were conducted using three-way unweighted means analyses of variance (ANOVA). Unweighted means ANOVA treats means of intact groups as representing samples with Ns equal to the harmonic mean of all groups, and is especially appropriate to control sampling artifacts. This procedure, however, provides a conservative index of effect size. ANOVAs were conducted to determine the relationship between medication receipt and combined influences of: (a) age, intellectual level, and behavior severity among adults; (b) intellectual level, residential setting, and presence of diagnosed psychiatric impairment; and (c) residential setting, behavior severity, and presence of diagnosed psychiatric impairment. The first two ANOVAs were constructed to address variables related to presence of psychiatric impairment. The third ANOVA was conducted to assess the combined influence of the variables most closely related to medication receipt in the first two ANOVAs. A two-way ANOVA was performed on medication receipt rates by diagnostic category and residential setting among persons with a psychiatric impairment. In addition, chi-square comparisons were made of medication receipt rates based on demographic and diagnostic characteristics. RESULTS As shown in Table 1, persons in the PDD group were similar in general characteristics to those in the DD group, except for less severe intellectual impairment (X2(3,N= 35,007) = 592.8, pc .OOl), more severe problem behavior (X*(4,N= 35,007) = 1627.1, p< .OOl), and higher receipt of psychotropic medications (X2(l,N=35,007)=2731.7,p< .OOl).

Age was related to receipt of psychotropics

(X2(4,N= 35,007) = 1950.2,

p < .OOl). Of DD persons aged birth to 4 years, 5 to 20, 21 to 44, 45 to 64,

and 65 years or older, 1.0070,26.3%, 24.7%,27.7%, and 11.5%, respectively, received psychotropics (X2(4,N= 31,666) = 933.4, p< .OOl). Of PDD persons in these same age groups, 28.6%, 72.7%, 65.4%, 73.9%, and 42.9%, respectively, received psychotropics (X*(4,N= 3,341) = 152.0, p< JOI). Sex

Sex was unrelated to whether persons received psychotropics; males and 23.7% of females received such medication.

26.1% of

30

J. W Jacobson

Intellectual Level Overall, greater use of psychotropics was observed for more severely disabled persons, with 19.1%, 20.9%, 34.7%, and 30.1% of persons with mild, moderate, severe, or profound mental retardation receiving these medications (X2(3,N= 35,007) = 643.9, p< .OOl). Corresponding patterns for DD persons were 12.1070, 15.7%, 30.6%, and 28.2% (X2(3,N=31,666)= 1022.24, p< .OOl) and for PDD persons were 56.8%, 64.4%, and 63.9% (X2(3,N= 3.341) = 29.0, p< .OOl). Residential Setting Overall, 10.1% of persons living with kin, 24.8qo in community care facilities, and 39.9% in institutions received psychotropics (X*(2,N= 35,007)=2801.5, pc.001). Among DD persons 6.9% living with kin, 18.8% in community care facilities, and 36.8% in institutions received psychotropics (X2(2,N= 3 1,666) = 2958.1, p < .OOl). These rates contrasted sharply for those for PDD persons, at 41.3% living with kin, 69.1% in community care facilities, and 80.0% in institutions (X*(2,N= 3,341) = 350.2, p< .OOl). Among 874 group homes (e.g., community residences and ICFs/MR within the CCF category), medication rates were found to vary, with no residents receiving psychotropics in 27.6% of the sites, from 1 to 50% of residents in 60.0% of the sites, from 51 to 80% in 9.7% of sites, and from 81 to 100% in 2.6% of the sites. Variation in medication rates was also noted among types of community care facilities. Overall, 16.2% of foster care, 27.9% of community residence, and 33.3% of ICF/MR residents received psychotropics (X*(2$= 11,436) 295.8, p< .OOl). Among DD persons 13.4% in foster care, 20.2% in community residences, and 24.3% in ICFs/MR received psychotropics (X*(2,N= 10,070)= 132.76, p< .OOl). Among PDD persons 67.3% in foster care, 64.4% in community residences, and 72.1% in ICFs/MR received psychotropics X?(2,N= 1,366) = 13.88, p< .Ol). Severity of Problem Behavior Overall, for the four groups ranked according to severity of problem behavior in ascending order, 6.7070, 22.0%, 38.0%. and 56.2% received psychotropic medication (X2(3,N= 35,007) = 6336.2, p< .OOl). Among DD persons, corresponding rates of psychotropics receipt were 5.9%, 18.7%, 32.7%, and 52.5% (X*(3&‘= 31,666) = 5338.8, p< .OOl). Again, higher rates were observed for the respective PDD groups at 35.1%, 52.8%, 65.7%, and 74.2% (X2(3,N= 3,341)=209.9, p< .OOl).

Psychotropic Medication

31

Age, Intellectual Level, and Behavior Severity

Rates of medication receipt are shown by age, intellectual level, and behavior severity (among adults) in Figure 1. Children were excluded to obtain appropriate cell Ns. Rates of medication receipt ranged from 3.6% (mild MR, age 65 + , no problem behaviors) to 69.0% (severe MR, age 45 to 64, severe problem behaviors). Significant interaction effects were noted for behavior severity x age, behavior severity x intellectual level, and intellectual level x age. Main effects were noted for behavior severity, age, and intellectual level (see Table 2). In general, persons aged 21 to 64 years, with severe or profound MR and severe behavior problems evidenced higher rates of medication receipt than those ages 65 years or older, with mild or moderate MR and negligible or nonsevere behavior problems. Intellectual Level, Residential Setting, and Psychiatric Impairment Rates of medication receipt are shown by intellectual level, residential setting, and diagnostic group in Figure 2. Rates of medication receipt ranged from 5.0% (DD, living with family, mild MR) to 88.8% (PDD, institution, moderate MR). Significant interaction effects were noted for residential setting x intellectual level x diagnosis, residential setting x diagnosis, and residential setting x intellectual level. Main effects were noted for diagnosis, residential setting, and intellectual level (see Table 2). In general, persons classified PDD living in community care facilities or institutions, at all intellectual levels, evidenced higher rates of medication receipt than

FIGURE 1. Percent of persons receiving psychotropic medication by age, intellectual level, and severity of problem behavior

32

J. W Jacobson TABLE 2. Summary of Analyses of Variance

Source Age, Intellectual and Behavior

Intellectual

Level, Setting,

Psychiatric

Impairment

F

P

558.07 9.09 119.29 9.48 23.13 3.85 1.24 5.119.29

3 3 2 9 6 6 18 33,796

186.02 3.03 59.65 1.05 3.86 0.64 0.07 0.15

1,240.13 20.20 397.67 7.00 25.73 4.27
.OOl .OOl ,001 .OOl .OOl ,001 -

.095 ,001

398.42 193.57 5.51 6.66 5.63 5.13 6.19 5.268.66

1 2 3 2 3 6 6 33,071

393.42 96.79 1.84 3.33 0.86 1.03 0.16

2,458.88 604.94 11.50 20.81 11.75 5.38 6.44 -

,001 ,001 ,001 .OOl ,001 ,001 .OOl

,069 ,035 ,001 .OOl .OOl .OOl .OOl

96.30 211.70 109.89 3.91 14.51 2.11 2.56 4.835.84

2 1 3 2 6 3 6 34,959

48.15 211.70 36.63 1.96 2.42 0.70 0.43 0.14

343.93 1,512.14 261.64 14.00 17.29 5.00 3.07 -

,001 ,001 ,001 ,001 ,001 .Ol .Ol

,020 .042 .022 .OOl .003 .0003 .0003

4.31 25.31 I .48 321.92

3 2 6 1,555

1.44 12.66 0.25 0.21

6.86 60.29 1.19 -

,001 ,001 -

,010 .070 _

W2

.001 ,003 .OOl -

and

PDD/DD (Dx) Residential setting (RS) Intellectual level (IL) DxxRS DxxIL RSxIL DxxRSxIL Error

1.88

Setting, Severity,

and Psychiatric

Impairment

Residential setting (RS) PDD/DD (Dx) Behavior severity (B) RSxDx RSxB DxxB RSxDxxB Error Psychiatric Category

MS

Level,

Residential

Behavior

df

Severity

Behavior severity (B) Intellectual level (IL) Age (A) BxIL BxA ILxA BxILxA Error

Residential

SS

Diagnostic and Residential

Setting Diagnostic Residential DxxRS Error

category (Dx) setting (RS)

33

Psychotropic Medication

LF CCF INS-T PROFOUNDMR

FIGURE 2.Percent of persons receiving psychotropic tial setting, and intellectual level

medication

by diagnosis, residen-

persons classified as DD, particularly those with mild living with their families or in community care facilities.

or moderate

MR

Residential Setting, Behavior Severity, and Psychiatric Impairment Rates of medication receipt are shown by residential setting, behavior severity, and diagnostic group in Figure 3. Rates for medication receipt ranged from 2.9% (DD, living with kin, no problem behaviors) to 88.5% (PDD, institution, severe behavior problems). Significant interaction effects were noted for behavior severity x residential setting x diagnosis, behavior severity x residential setting, residential setting x diagnosis, and behavior severity x diagnosis. Main effects were noted for diagnosis, setting, and behavior severity (see Table 2). In general, persons classified as PDD, living in institutions and community care facilities, with any reported problem behavior evidenced higher medication receipt rates as compared to persons classified as DD, living with family or in community care facilities with negligible or nonsevere problem behavior.

Diagnostic Category and Residential Setting Data on medication receipt rates were also reviewed with regard to DSMII diagnostic categories. Numbers of cases sufficient for analyses were avail-

34

FIGURE 3. Percent of persons receiving psychotropic tial setting, and severity of problem behavior

medication

by diagnosis,

residen-

able for four categories: organic brain syndrome, psychosis, personality disorder, and childhood behavior disorder. Rates of medication receipt were contrasted across residential settings and are shown in Table 3. Rates of medication receipt were found to differ by residential setting, and diagnostic category. Medication receipt rates were highest among persons with diag-

TABLE 3. Percent of Persons Receiving Psychotropics by Type of Psychiatric Impairment and Residential Setting Live with Family (Q/N)

Diagnosis

Community Care Facility Vo/N)

Institution (Q/N)

All Cases (Q/N)

Organic brain syndrome

33.6/146

60.6/66

83.9/31

47.3/243

Psychosis

57.8/325

82.3/181

84.8/164

7 1.01670

Personality

disorder

40.6/212

65.4/136

89.1/55

55.6/403

Childhood disorder

behavior

32.6/181

59.2/49

76.2/21

40.6/25 1

44.2/864

70.8/432

84.5/271

58.5/1,567

Total for diagnostic groups

Psychotropic Medication

35

nosed psychosis, and lowest overall among persons with childhood behavior disorders. Strikingly, medication rates were substantially greater within community care facilities and institutions than within natural family contexts regardless of diagnostic category. Summary of Findings

As in previous prevalence studies, it was found that psychotropic medication receipt rates were higher in PRFs than in CCFs and in CCFs in comparison to family settings. Furthermore, medication receipt rates were lower for children, adolescents, and elderly individuals than for young and middle-aged adults, regardless of sex or residential setting. Higher rates of psychotropic medication were evident for persons with severe or profound mental retardation compared to those with mild or moderate mental retardation, and in general, for persons with a reported psychiatric impairment when compared to their nondiagnosed peers based on age, intellectual level, behavior severity, or residential setting. Similarly, rates of psychotropic medication receipt increased with severity of problem behavior, with persons with problem behavior rated as severe being eight times more likely to receive such treatment compared to those not evidencing problem behavior. Finally, among persons with a psychiatric impairment, the rate of medication receipt varied with diagnostic category. Although persons with psychiatric impairment were more likely to receive psychotropics, three-quarters of the persons receiving psychotropics do not have a documented psychiatric impairment and nearly one-quarter have neither a psychiatric impairment nor behavior problems rated as moderate or severe in degree. DISCUSSION Previous studies have shown that the mentally retarded persons most likely to receive psychotropic medications are classified as mildly mentally retarded, adult, carry a psychiatric diagnosis, and live in institutions or in more restrictive types of CCFs. Similar findings were obtained in the current study, except for the relationship to intellectual level. As noted by Martin and Agran (1985), differences among study samples could account for divergent findings on the relationship between intellectual level and medication receipt. Factors that remain ill-considered in predicting psychotropic medication usage, however, include the programmatic performance and capabilities of residential settings, and treatment orientation of the medical practitioner. Efforts to improve medication practices in PRFs have focused on standard setting and review processes. Less attention has been given to physician practices or to augmentation of staffing levels to expedite alternative intervention capability.

36

J. W Jacobson

When CCFs of varying types have been compared, higher medication rates are evident in more restrictive settings, despite (as in the current study) lower medication rates for persons with similar demographic and clinical characteristics in less restrictive and nonrestrictive (i.e., family) settings. Psychiatric diagnosis and medication receipt may reflect the availability and accessibility of physicians, whether physicians are staff or consultants, whether intervention referrals are made to psychologists or physicians, and whether psychoactive medication is acceptable to care providers as a treatment strategy. The higher status of private medical practice compared to public employment, and the low status of severely disabled persons in the health care hierarchy may predispose to provision of psychiatric services by less-experienced or generalist physicians (Garrard, 1982). Less-experienced and generalist physicians are more likely to prescribe psychotropic medication rather than undertake alternative treatment compared to more experienced or specialized practitioners (Balter & Levine, 1969; Hadsall, Freeman, & Norwood, 1982; Raft, Davidson, Toomey, Spencer, & Lewis, 1975; Siegel, Dlugacz, Fischer, & Alexander, 1983). Physician prescription practices are affected by the patient’s diagnosis, demographics, and expectations, and by the physician’s education, age, attitude toward drug therapy, and contact with other physicians (Hadsall et al., 1982; Hemminki, 1975; Linn, 1971). Because programs, families, and professionals are the referral sources for psychiatric assessment and treatment for most severely disabled persons, preselection of individuals may convey an implicit expectation that psychotropic medication will be the intervention strategy of choice. Furthermore, facilities may more frequently refer disabled persons for psychiatric evaluation than do families. Possibly, facilities are-less tolerant of certain behavior problems, or are less effective in managing behavior problems. Program evaluation efforts have not dealt adequately with the roles and performances of physicians and psychologists in service settings. Because these disciplines provide, in concert, the primary avenues drawn upon to legitimate psychotropic and alternative interventions, the relation of intervention practices to practitioner education, diagnostic biases, decision-making, team participation, referral biases, and program capabilities must be more fully examined.

REFERENCES Agran, M., & Martin, J. E. (1985). Establishing socially validated drug research in community settings. Psychopharmacology Bulletin. 21, 285-290. Aman, M. G. (1983). Psychoactive drugs in mental retardation. In J. L. Matson & F. Andrasik (Eds.), Treatment issues and innovations in mental retardation (pp. 455-513). New York: Plenum Press.

Psychotropic

Medication

37

Aman, M. G. (1984). Drugs and learning in mentally retarded persons. In G. D. Burrows & J. S. Werry (Eds.), Advances in humon psychopharmacology (Vol. 3, pp. 121-163). Greenwich, CT JAI Press. Aman, M. G., Field, C. J., & Bridgman, G. D. (1985). City-wide survey of drug patterns among non-institutionalized mentally retarded persons. Applied Research in Memo1 Refurd&on, 6, 159-171. American Psychiatric Association (1968). DSM-II: Diagnostic and slatislical manual ofmenlal disorders. Washington, DC: Author. American Psychiatric Association (1980). DSM-III: Diagnostic and statistical manual ofmental disorders. Washington, DC: Author. Baiter, M. B., & Levine, J. (1969). The nature and extent of psychotherapeutic drug usage in the United States. Psychopharmacology Bulletin, S,(4), 3-13. Breuning, S. E., & Poling, A. D. (1982). Pharmacotherapy. In J. L. Matson & R. P. Barrett (Eds.), Psychopathology in the mentally retarded (pp. 195-243). New York: Grune & Stratton. Davidson, N. A., Hemingway, M. J., & Wysocki, T. (1984). Reducing the use of restrictive procedures in a residential facility. Hospital and Community Psychiufry, 35, 164-167. deSilva, R. M., & Higgenbottom, J. A. (1983). Intellectual functioning and community placement. Canadu’sMentalHeulth, 31(4), 12-13. Eyman, R., & Call, T. (1977). Maladaptive behavior and community placement of mentally retarded persons. American Journal of Mental Deficiency, 82, 137-144. Gadow, K. D. (1985). Prevalence and efficacy of stimulant drug use with mentally retarded children and youth. Psychopharmacology Bulletin, 21.291-305. Garrard, S. D. (1982). Health services for mentally retarded people in community residences: Problems and questions. American Journalof Public Health, 72, 1226-1228. Greer, J. G., Davis, T. B., & Yearwood, K. (1977). Drug treatment: Factors contributing to high risk in institutions. Exceptionul Children, 43,451-453. Greer, J. G., Davis, T. B., & Yearwood, K. (1978). Drug treatment: Factors contributing to high risk in institutions. International Journal ofRehabilitation Reseurch, 1, 19-26. Guahieri, C. T., & Keppel, J. M. (1985). Psychopharmacology in the mentally retarded and a few related issues. Psychopharmacology Bulletin, 21, 310-315. Hadsall, R. S., Freeman, R. A., & Norwood, G. J. (1982). Factors related to the prescribing of selected psychotropic drugs by primary care physicians. Social Science ond Medicine, 16, 1747-1756. Hemminki, E. (1975). Review of literature on factors affecting drug prescribing. SocialScience ond Medicine, 9, 11l-l 16. Hill, B. K., Balow, E. A., & Bruininks, R. H. (1985). A national study of prescribed drugs in institutions and community residential facilities for mentally retarded people. Psychopharmacology Bulletin, 21, 279-285. Intagliata, J., & Rinck, M. A. (1985). Psychoactive drug use in public and community residential facilities for mentally retarded persons. Psychophormucology Bulletin, 21, 268-277. Jacobson, J. W. (1982a). Problem behavior and psychiatric impairment within a developmentally disabled population I: Behavior frequency. Applied Research in Mental Retardation, 3, 121-139. Jacobson, J. W. (1982b). Problem behavior and psychiatric impairment within a developmentally disabled population 11: Behavior severity. Applied Research in Mental Retordution, 3, 369-381. Jacobson, J. W., & Janicki, M. P. (1985). Functional and health status characteristics of persons with severe handicaps in New York State. Journal of the Association for Persons with Severe Handicaps, 10, 5I-60. Janicki, M. P., & Jacobson, J. W. (1982). The character of developmental disabilities in New York State. International Journal of Rehabilitation Research, 5, 191-202.

38

J. W Jacobson

Linn, L. S. (1971). Physician characteristics and attitudes toward legitimate use of psychotherapeutic drugs. Journal of Health and Social Behavior, 12, 132-140. MacEachron, A. E. (1983). Psychotropic and general drug use by mentally retarded persons: A test of the status model of drug use. Child and Youth Services, 6 (l/2), 89-102. Martin, J. E., & Agran, M. (1985). Psychotropic and anti-convulsant drug use by mentally retarded adults across community residential and vocational placements. Applied Research

in Mental Retardation, 6, 3-49. Mouchka,

S. (1985). Issues in psychopharmacology

with the mentally

retarded.

Psychophar-

macology Bulletin, 21,262-267. Office of Mental Retardation and Developmental Disabilities. (1978). DDIS user’s guide. Albany, NY Author. Pullman, R. M., Pook, R. B., & Singh, N. (1979). Prevalence of drug therapy for institutionalized mentally retarded children. Australian Journal of Mental Retardation, 5, 212-214. Raft, D., Davidson, J., Toomey, T. C., Spencer, R. F., & Lewis, B. F. (1975). Inpatient and outpatient patterns of psychotropic drug responding by non-psychiatrist physicians. American Journal of Psychiatry, 132, 1309-1312. Schalock, R. L., Foley, J. W., Toulouse, A., & Stark, J. A. (1985). Medication and programming in controlling the behavior of mentally retarded individuals in community settings.

American Journal of Mental Deficiency, 89, 503-509. Schroeder, mental

S. R., Rojahn, J., & Mulick, J. A. (1978). Ecobehavioral organization of developday care for the chronically self-injurious. Journal of Pediatric Psychology, 3, El-

88. Schroeder, S., Sprague, R. L., Gualtieri, C. T., & Thompson, T. (1986). The continuing sad saga of pharmacotherapy for persons with mental retardation. Psychology and Mental

Retardation, 12(l), 3-4. Siegal, C. Dlugacz, J., Fischer, S., & Alexander, M. J. (1983). The effects of a computerized drug order review system. In R. Dayhoff (Ed.), Proceedings of theseventh annualsymposiurn on computer applications in medical care (pp. 207-210). Silver Springs, MD: Institute of Electrical & Electronics Engineers. Sisson, L., & Breuning, S. (1983). Medication effects. In J. Matson & S. Breuning (Eds.), Assessing the mentally retarded. (pp. 143-179), New York: Grune & Stratton. Szymanski, L. S. &Crocker, A. C. (1983). Mental retardation. In H. 1. Kaplan & Sadock, B. J. (1983). Comprehensive textbook of psychiatry (pp. 1635-1671). Baltimore, MD: Williams &Wilkins.